A case series of transplant recipients who despite immunosuppression developed inflammatory bowel disease

Abstract

Objectives: We describe 14 patients who developed inflammatory bowel disease (IBD) after transplantation despite immunosuppression.

Methods: Using an electronic medical archival retrieval system, records of 6800 liver and kidney transplant patients were searched for evidence of IBD. The pathology was reviewed, and infectious etiologies were excluded.

Results: Fourteen patients developed IBD after transplantation. Twelve patients had undergone liver transplantation, and two kidney transplantation. Four had transplantation for autoimmune hepatitis; four for non-A, non-B, non-C hepatitis; two for primary sclerosing cholangitis; one for giant cell hepatitis; one for biliary atresia; one for polycystic kidney disease; and one for obstructive uropathy. Mean age at development of IBD was 38 yr. Mean time to development of IBD after transplantation was 4 yr. Endoscopically there were two cases limited to the left side, eight of pancolitis, of which one had terminal ileal disease, and four of patchy colitis. Histology was consistent with ulcerative colitis in nine patients and Crohn's disease in five. Patients with ulcerative colitis either responded and remained in remission on maintenance therapy (seven of nine) or were refractory and required a colectomy (two of nine). Patients with Crohn's disease continued to have flares despite treatment (five of five).

Conclusion: 1) New onset IBD can develop after solid organ transplantation, despite use of immunosuppressive therapy. 2) A full spectrum of IBD can be seen after transplantation. 3) Study of these patients could shed light on why immunosuppression is not uniformly effective for IBD and provide clues to the inflammatory determinants of IBD.